Public_Health_and_Primary_Care

Public Health and Primary Care I have chosen to base my care study on Lillian, a 76 year old widow, who has Chronic Obstructive Pulmonary Disease (COPD). Lillian lives on her own in a bungalow, her step son Frank, visits once a week. He is the only family member that Lillian has contact with. Lillian was referred to the district nurse team from the local hospitals acute medical ward as she had suffered from a serious chest infection and increased exacerbation. The staff on the ward raised concerns as with exacerbation of COPD her fev 1/fvc ratio was 50 % which meant that she has severe airflow obstruction (Scullion.J 2007). Lillian’s chronic cough and sputum was one of the reasons Lillian was admitted. Treatment used to help this, were Tiotropium 400, which is a long acting anticholinergics this is used for symptom control (Mims 2007). A long acting beta agonist was also used as a steroid therapy. National Institute of Clinical Excellence (NICE2004) advocates the use of a spiromentry as being essential to diagnose and assess the severity of COPD. This was used by the COPD nurse to measure Lillian .Other supportive measures could be the use of a nebuliser and influenza vaccination. This can be reflected by the local trusts guidelines for medicine management of COPD. The term COPD covers both emphysema and chronic bronchitis (West 2004). COPD affects the lungs by causing inflammation of the airways, thus causing the lungs to produce too much mucus. Producing mucus is something which is needed as it keeps the airway moist and supple, also by producing mucus it flushes the airways free from dust and particles which a person may breathe in. Over production of mucus caused by COPD can cause the mucus to become too thick and is usually coughed up as phlegm or sputum. In COPD the sacs, known as alveoli cannot return to their usual shape or do they have as much elasticity and when this is the case the airways become thick and swollen, which can also cause them to become obstructed. Narrowing of the airways increases the amount of breathing difficulty that a person may have. In a healthy person the lungs have the ability to expand and deflate when a person breathes, but due to the narrowing caused by COPD that ability is affected and breathing or breathlessness becomes an issue. During Lillian’s admission, baseline observations were carried out, temperature, pulse, respirations and blood pressure. Lillian’s pulse oximetry was scoring 85% which is low within a patient who does not suffer from COPD but within a patient with COPD it is very common, although still raises concern. Lillian requires continual supplementary oxygen at home so within the hospital setting low flow oxygen was given as over a long period of time, which is aimed to improve prognosis (Bandit 2000). Lillian suffers from the long term illness COPD. The district nurse visits twice a week to offer support for Lillian and to provide health education with regards to oxygen therapy and medication. Lillian has a care package in place which was arranged by social services over a year ago, Lillian received support from carers once a day to assist with all activities of daily living as they were neglected, when her COPD started to deteriorate and which has lead to an increased shortness of breath. When talking to Lillian you could see that she felt socially isolated and depressed and she was very dependant on her carer and step son. Economic deprivation has lead to a reduces access to Lillian’s requirements to a healthy life including affordable, nutritious food, adequate housing, healthcare and a good social support network such as family, friends and community groups( WHO 2005). Lillian’s lacks this as she only has support from her step son and as her COPD has deteriorated she is unable to leave the house and with little money from her pension she is unable to eat nutritious foods. The deterioration of Lillian’s COPD has lead to her being unable to sit or lay down so therefore pressure sores have developed on both elbows. The term pressure sore is used to describe any area of damaged skin or underlying tissue caused by direct pressure or shearing forces (Doughty, Lister 2004). This has developed as Lillian is unable to sit or lay down due to her increased breathlessness. The National Service Framework for older people (DOH2001a) has identified the need to reduce the risk of pressure damage in older people in both community and hospital settings (Doughty, Lister 2004). A patient with healthy lungs mainly found in non smokers has sacs which easily fill up with air when they breathe in and deflate when carbon dioxide is breathed out. The alveoli are springy and spongy and the passageways that lead to the alveoli are unobstructed and wide open (Help with smoking.com). Patients like Lillian with COPD, have airways which are surrounded by muscle that can hold open or squeeze them to make them narrow. Within Lillian’s respiratory system these muscles may squeeze her airways a bit too narrow, which makes the tubes narrower and makes it harder for her to breathe. Lillian finds it difficult to take a deep breath and her chest is very tight this is because the air sacs in Lillian are over stretched and are broken down; this is why Lillian finds it more comfortable to stand. Stagnant air gets trapped in her air sacs and it leaves no room for new air to get in. As her condition has deteriorated, the lining of her airways have become inflamed and swollen, which has lead to them becoming even more narrow which in turn makes breathing more difficult. Lillian’s COPD occurred from her smoking. The World Health Organisation (WHO) predicts that by 2020 COPD will rise, its current ranking of 12th most prevalent disease worldwide to 5th and from 6th most common disease to 3rd (Murry 1997). Another study by WHO (2002 p.76) states that COPD is the 3rd largest cause of respiratory death and accounts for 20% of respiratory mortality. Smoking cigarettes, both active and passive is considered the major causative factor in development of COPD. More than80% of COPD patients is or were smokers (Gibson 2003 p.113). Tobacco contains thousands of poisonous chemicals, which when breathed in can remain in the lung and cause damage. The tar in the cigarette smoke is particularly damaging as long term exposure can lead to narrowing, destruction of the bronchioles, lung protection and filter system (Haplin.D 2007). White paper saving lives our healthier nation (D.O.H) had lead to am increase in awareness of the importance of public health and this policy outlines a set of objectives that guide, define, proxies and scopes action in response to health needs like smoking. It helps set priorities in health care provision and gives a frame work for health care delivery (Mitcheson.j.2008). WHO 2008, recognizes that COPD is a major public health importance and that smoking is a major public health issue, which is linked with smoking and is one of the biggest threats to public health. The NHS set up a stop smoking service in 1999 in all health action zones, which were established in areas of deprivation and poor health, in order to tackle health inequalities. The geographical area in which Lillian lives is included in this. The aim of the WHO is to reduce the toll of disease, disability and premature death (WHO2004). The high prevalence of COPD has encouraged a review of the British COPD guidelines culminating in the publication March 2004 BTS guidelines endorsed by the National Institute for Clinical Excellence (NICE). These guidelines set examples for the management of COPD. The strategies relate to Lillian would be to increase her awareness of the disease by educating her. The National Service Framework (NSF) for long term conditions and the NSF COPD, which is out later this year, sets aims to produce advice that will lead into working policies, which take into account the needs of the patients. These guidelines would be beneficial for Lillian, as they are realistic about the capability of the NHS and other organisations. This will improve quality and access to COPD services, reducing inequalities and health care costs. The British Lung Foundation (BLF) is also working inline with the department of health to help achieve standards and goals like care provided by the inter-professional team and early support when discharging a patient like Lillian from hospital. The goals will support the White Paper and help to reduce smoking. For community based interventions to be successful you need good partnerships not only with health care professionals but community organizations for example’ breathe easy groups, policy makers, businesses and the patient. The role of the nurse in supporting Lillian with her health problems would be to promote health and prevent illness. COPD is a life limiting disease. The nurse should set therapeutic goals by reducing symptom, increasing function and improving quality of life (Halpin 2001, NICE2004). The nurse should use evidence based practice to improve standard of care for Lillian. The nurse would act as an advocate for Lillian helping her to access relevant health and social care necessary. Lillian has little knowledge about her illness, so the nurse would have to make independent decisions about her care based on what the nurse knows about her. From this the nurse and inter-professional team would be able to address problems that may occur and be able to support and comfort Lillian and her step son. This would be achievable with working in line with the inter-professional team. One of the main concerns for the nurse supporting Lillian would be to encourage her to stop smoking as this is by far the most important factors it would slow the rate of decline in the lung function, which would help to enhance Lillian’s quality of life. Within the community in Lillian’s area a smoking cessation nurse offers support and advice as she is house bound the nurse is able to offer the support at home. The nurse may have to advocate for the patient, at times. Within the community setting the NHS can offer pulmonary rehabilitation programmes for Lillian and within a home setting. While in hospital the nurses carried out a nursing assessment, which looked at Lillian’s ability to carry out the 12 activities of daily living, which include communicating, breathing, eating, drinking, maintaining a safe environment, eliminating, cleansing and dressing, mobilising, controlling body temperature, working and playing, expressing sexuality, sleeping and death and dying (Angleton and Chalmers 2000). This assessment helps inter-professional teams, evaluate care related to Lillian. Record keeping is a fundamental part of Lillian’s care and a key aspect of the nurse’s accountability. It has a major impact on the quality of care ensuring that everyone involved in the care of Lillian is kept up to date. To ensure they are accurate, it is vital to complete records as soon as possible (nursingtimes, 2008:104). As a nurse you would have to follow this, as if you leave record keeping to long you may not document the correct information and it will not be accurate in relation to Lillian’s care which will then cause a break down in communication within the inter-professional team. Strategies which are used are addressed by the NMC code as it reflects on changes in practice, policies and legislation. The importance of effective communication means better patient care. Information is fundamental to choice and making informed decisions. Without information, there is no choice. Information helps knowledge and understanding. It gives the patients power and confidence to engage as partners with their health service (DOH2004). This is important because if you communicate with Lillian in a way she can understand about her illness and care, it will be more affective, when delivering information and support. Unfortunately there is no cure for COPD. Lillian has medication to relieve her symptoms, as Lillian is facing a life treating illness she would need support from within the inter-professional team. The nurse and inter-professional team would work and communicate with each other, to provide palliative care this would be by helping Lillian and her step son to cope with the condition and treatment, this would include pain management, health education, nutrition and easing distress services from the hospice are also available for COPD patients. Lillian has her own unique health needs and the most common issues that should be addressed by the inter-professional team would be reducing symptoms which would be the role of the group and district nurse administering, prescribing medication and supplying health advice and clear information for Lillian concerning the use of her medication. Maintaining quality of life would be the role of the occupation health therapist (OT) and social services. This would involve Lillian’s bungalow to suit her needs and providing carers to assist with her activities of daily living. The community dietician would be able to provide nutritional support and dietary advice to Lillian. Lillian’s discharge plan started at her point of admission. This was a complex process as it required input from many members of the inter-professional team. Careful consideration is paramount to ensure safe and effective discharge. Within the hospital and community setting it was important to establish Lillian and her step son, frank’s, perspective and expectations so all inter professionals have a baseline to work from, in order to achieve a seamless discharge. The inter-professional team worked with Lillian to ensure to ensure a full assessment of activities of daily living was carried out. The OT and physiotherapist both carried out an assessment of activities of daily living, for Lillian’s home prior to her discharge. This was to monitor if she could undertake simple tasks like washing up. The dietician would be able to offer support for Lillian and frank on what to eat and making use of her oxygen at mealtimes. Lillian is malnourished due to her increased work of breathing which has made her feel to breathless to eat. Due to complex discharge needs, seamless care wasn’t evident. Lillian’s chest infection caused her stay in hospital to increase. Her mobility had decreased over time. Lillian had a delayed discharge as the equipment was not set up in her bungalow. Members of the inter-professional team all provided effective communication by having multi disciplinary meetings to share practice and ways of different collaborative working. Lillian and her step son, Frank, were invited to be involved in the decision making process. Involved in discharge planning was the District Nurse, COPD nurse, OT, physiotherapist, social services, dietetics and pharmacy. They all worked together to ensure Lillian received optimum care. The above statement is supported by Catwalk 2002. Healthcare needs are dependent on the effective working of the multi disciplinary team, which as a nurse I agree with. Because Lillian is being cared for within the community setting all members within the inter-professional team would need to follow the guidelines of the community care act (1990). This is to insure the delivery of service to Lillian is of a high standard and is meeting her needs. Collaborative working means achieving better health and better well being for Lillian. Within the community an expert patient programme is set up to enhance self management skills for patients like Lillian who suffer from long term illness. It usually consists of a patient, who has the illness for a long period of time. The programme provides help, support and advice on relaxation, symptom management. This would not only address the needs of Lillian, but also her step son, and would hopefully not make them feel isolated. The inter-professional team would be able to offer psychological support and educate her on how to manage her disease. In conclusion, this care study has been good to analyse COPD as a public health issue. There is clear evidence that COPD is linked to smoking. There is clear evidence that the decline of lung function and its acceleration in COPD patients is cased by smoking (Fleactor&Petoth 1977). The epidemiology of COPD has helped to monitor and evaluate changes in health and illness and the delivery of health services. I discovered that high economic and social cost is sufficient motivation for health care professionals to seek and find the most efficient methods of delivering high quality care to Lillian. Early diagnosis and effective follow up care would help to achieve this. From working in the community I recognised how important it was to use effective communication between the inter-professional team and that any breakdown between them would affect the care of Lillian and increase her stay in hospital. The role of a nurse is to restore, maximise and maintain the health and well being of Lillian and act as an advocate. Seamless care was not evident in this care study. Lillian’s discharge was not seamless as the appropriate home equipment was not set up in time. This was due to poor communication and budgetary constraints. If the inter-professional team within the hospital setting had better communication, this could have been avoided. The aim of multidisciplinary meetings is so all parties can high light any issues and solve them in the quickest way, so not to hinder Lillian’s discharge. This would then be in line with government policies. Public health The government appointed a Minister for public health for the first time in 1997; this minister had to cross- departmental responsibility to coordinate issues across the government. The English public health strategy (D.O.H 1998a, 1999) recognises the importance of all these other services in determining health, and the importance of collaboration is mirrored in policies across the UK. Public health definition…… Smoking Smoking harms nearly every organ of the body, causing many diseases, and reduces quality of life and life expectancy. Smoking causes lung cancer, bronchitis, emphysema, heart disease, and cancers in other organs including lip, mouth, throat, bladder, kidney, stomach, liver and cervix. As a result of this ill health, it is estimated that in 2006/2007 445,100 adults over the age of 35 were admitted to NHS hospitals in England. This is equivalent to about 8,500 hospital admissions per week, or more than 1,200 per day (Statistics on Smoking 2008). For every death caused by smoking, approximately 20 smokers are suffering from a smoking related disease. Around 13 million adults smoke in the UK, 29% of men and 25% of women. Smoking is highest among those aged 20-34: 35% of men and women in this age group smoke. Among older age groups prevalence gradually declines with the lowest smoking rate among people aged 60 and over; 16% smoke in this age group. Men and women in the unskilled manual socio-economic group are more likely to smoke than people in a professional group (HypnotizeMe.com). Every year, around 120,000 smokers in the UK die as a result of their habit. Smoking kills around 6times more people in the UK than road traffic accidents (3,391), other accidents (8,933), poisoning and overdose (3,157), murder and manslaughter (459), suicide (4,485) and HIV infection (180) all put together (20,641) in total- 1999 figures ( HypnotizeMe.com). One or two long-term smokers will doe prematurely as a result of smoking- half of these in middle age. One quarter will die after 70 years of age and one quarter before, with those dying before 70 losing on average 21 years of life (Peto 1994). Nicotine Nicotine an alkaloid is a powerful and addictive drug. When inhaled in, tobacco smoke is fast acting, reaching the brain within 10-19 seconds. Most people who smoke are dependant on the nicotine in cigarettes (Nicotine Addiction 2000). When the cigarette is lit, the nicotine in the tobacco leaf evaporates, attaching itself to minute droplets in the tobacco smoke inhaled by the smoker. Nicotine stimulates the central nervous system and increases the heart rate. These effects are in part the reason why people enjoy smoking. The speedy absorption of nicotine through cigarette smoking gives the smoker a rapid reinforcement to continue (Nicotine Addiction of in Britain). Nicotine addiction is not only physical; it also involves a psychological and emotional dependence upon smoking as a means of coping with stress, boredom, anxiety or anger. Smoking becomes an automatic habit and the difficulties smokers experience when stopping are due to their association of smoking with everyday activities. Many smokers believe that a cigarette helps them to relax. The reality is that the nicotine ‘hit’ satisfies the body’s craving. This is a classic cycle of addiction – a craving following by satisfaction, followed by withdrawal (Raw). When this cycle is repeated many times a day, it is easy to understand just how addictive smoking is and how difficult it is for a heavy smoker to stop. Addiction to nicotine has not been recognised as a medical or social problem in Britain. Once addicted smokers are unable to give up smoking even when they develop diseases caused by smoking. On average women smokers go through the menopause up to 2years earlier than non-smokers and are at a greater risk of developing osteoporosis. Smoking has been associated with increased sperm abnormalities and is a cause of impotence. It can affect both your sense of taste and smell. Smokers are more likely to develop facial wrinkles at a younger age and have dental hygiene problems (Smoking and Disease 2007). People that breath in second hand smoke are at risk of the same diseases as smokers including, cancer and heart disease because second hand smoke contains 4,000 toxic chemicals. It is estimated that second hand smoke causes thousands of deaths each year ( Smokefree NHS). The toxic substances in second hand smoke include over 69 cancer- causing chemicals. The 1998 Government White Paper, Smoking Kills, put forward a whole range of proposals to help people give up and to discourage people from smoking in the first place, including moves towards barring tobacco advertising. Public health policies and initiatives are now in place in all four UK countries around smoking cessation. Nurses remain key to providing the individual help and support that is necessary to help people stop smoking. Success is possible, even for those smokers who are heavily addicted. All nurses can – need to be – involved, across every speciality and work environment. Help people to stop smoking saves lives. Tobacco use killed 100 million people last century, more than the number killed in both World Wars. The WHO estimates that this centaury there could be 1 billion deaths, 70% of which occur in developing countries (WHO 1999). The WHO calls this crisis ‘The Silent Epidemic’. To help advert this predicted death toll, the WHO is supporting the implementation of a global initiative called the International Framework Convention on Tobacco Control. Studies show that interventions to help people stop smoking are beneficial, not just to the individual smoker but also to society at large. Smoking places a great burden on the health service. Health care costs for smokers at any given age are as much as 40% higher than non-smokers. The cost to the NHS of treating people with smoking related diseases is £2.7 Billion a year (Facts at a glance). This includes the cost of hospital admissions, GP consultants and prescriptions. The government also pays for sickness/invalidity benefits, widow’s pensions and other social security benefits for dependents. An analysis of the cost benefits of achieving the government’s targets to reduce smoking has shown that £524 million could be saved due to the reduction in the number of heart attacks and strokes. Clinical trials have shown that Nicotine Replacement Therapy (NRT) doubles the chance of success of smokers wishing to stop (Raw 1998). NRT does not provide a complete replacement for cigarettes, nor eradicate the need for willpower. However, it does help with the management of withdrawal symptoms associated with the cessation of smoking whilst allowing the smoker to concentrate on breaking the social and psychological habits. NRT is not a magic cure but it can help smokers who are motivated to stop and is most effective when used in conjunction with professional advice and support. Smoking cessation interventions have proved to be excellent value for money. Results for smoking cessation interventions in the UK range from £212 to £ 873 per life year gained. The NHS Plan (July 2000) (DOH 2000) stated that specific targets to reduce health inequality would be developed. World leading Smoking Cessation Services were to be a key component of efforts to achieve narrowing of the health gap between socio-economic groups. These services would focus on the heavily dependant smoker and pregnant woman. Guidance from the National Institute for health and Clinical Excellence (NICE) recommends that every smoker should be advised to quit unless there are exceptional circumstances.